Forms - Arkansas Department of Transformation and Shared Services

Employee Benefits

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Arkansas State Employees

ARBenefits Forms

Election Form
Change Form
Spousal Affidavit
Appeal Request Form
2nd Level Appeal Form
Continuation of Insurance due to Incapacity
Authorization to Release Information Form
Authorization to Revoke Release of Health Information Form

Health Savings Account (HSA) Forms

2024 HSA Enrollment Form
HSA Claim Form
HSA Change in Status Form
HSA Transfer Request

Flexible Spending Account (FSA) Forms

2024 FSA Enrollment Form
FSA Claim Form

Voluntary Coverage Forms

Delta Dental Enrollment Form
Humana Vision Application
Colonial Life Enrollment Brochure

Other Forms

Non-AASIS Matching Form
Non-AASIS Termination or Retirement Form
EBD Event Request Form
Pharmacy Reimbursement Claim Form
AR Diamond Plan Opt-Out Form
Request to Remove/Change IT168-Life & IT377-Misc. Plans Form

Public School Employees

ARBenefits Forms

Election Form
Change Form
Spousal Affidavit
Appeal Request Form
2nd Level Appeal Form
Continuation of Insurance Due to Incapacity
Authorization to Release Information Form
Authorization to Revoke Release of Health Information Form

Voluntary Coverage Forms

Colonial Life Enrollment Brochure

Other Forms

EBD Event Request Form
Pharmacy Reimbursement Claim Form

Health Savings Account Forms
*Only use the forms below if your District uses Optum Financial through the State*

2024 HSA Enrollment Form
HSA Claim Form
HSA Change in Status Form
HSA Transfer Request

Retirees

ARBenefits Forms

Retirement Election Form
Spousal Affidavit
Appeal Request Form
Bank Draft Authorization
Change to Bank Draft Authorization
Retiree Change of Address Form
Pharmacy Reimbursement Claim Form *For Health Advantage Retirees Only*
Billing Recap

Voluntary Coverage Forms

Dental and Vision Application
Colonial Life Retiree Enrollment Form
Colonial Life Retiree Change Form
Colonial Life Retiree Beneficiary Change Form

Retirement Packets

2024 State Employee Retirement Packet
2024 Public School Employee Retirement Packet

Active Employees

Arkansas State Employees

Public School Employees

Retirees

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Active Employees

Arkansas State Employees

Public School Employees

Retirees

About TSS

Resources

Contact Us

Your Arkansas.gov

Top Online Services

Helpful Information

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